Baylor University Medical Center, Baylor Scott & White Health Dallas, TX
Ashton Ellison, MBChB1, Anh D. Nguyen, MD2, Jesse Zhang, BS3, Roseann Mendoza, FNP3, Eitan Podgaetz, MD, MPH4, Rhonda F. Souza, MD2, Stuart J. Spechler, MD, FACG2, Vani Konda, MD, FACG2; 1Baylor University Medical Center, Baylor Scott & White Health, Dallas, TX; 2Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, TX; 3Center for Esophageal Diseases, Baylor University Medical Center, Dallas, TX; 4Center for Thoracic Surgery, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, TX
Introduction: High resolution manometry (HRM) with Chicago Classification (CC) interpretation is the gold standard for defining esophageal motility disorders. However, HRM may reveal abnormalities that do not meet CC criteria, or may be normal in patients with esophageal symptoms. Also, EGJ outflow obstruction (EGJOO) comprises a heterogeneous group of disorders that may require disparate treatments. We have utilized EndoFLIP for suspected dysmotility, and have reviewed our experience to explore the impact of EndoFLIP on management. Methods: We reviewed medical records for patients in our Center for Esophageal Disease with EndoFLIP performed November 2018-March 2020. We recorded EGJ diameter (D) and distensibility index (DI) at the 60 mL volume, and topography contraction patterns [repetitive antegrade (RACs), repetitive retrograde, disorganized diminished, hypercontractile, and sustained esophageal contractions (SECs), or absent contractility] at the 40 and 60 mL volumes. We also recorded CC diagnosis, symptoms [Eckardt score and Brief Esophageal Dysphagia Questionnaire (BEDQ)], working diagnosis, and EndoFLIP-guided change of therapy (botulinum injection, pneumatic dilation, or myotomy). Results: We performed EndoFLIP on 249 patients with esophageal symptoms who had HRM and no prior foregut surgery. Table 1 shows D, DI, symptom scores, and EndoFLIP impact on diagnosis and therapy. Endoflip confirmed the diagnosis in all patients with achalasia by HRM and did not alter management. Among 97 patients with EGJOO, 50/97 (52%) of EGJOO patients had low DI (mean 1.3) with abnormal patterns on FLIP in all cases and were considered to have a primary EGJOO dysmotility disorder. These cases were also less likely to have any RACs compared to those with normal DI (12% v 32%, p< 0.05). In 2 (18%) of 11 patients with absent contractility and IRP < 15mmHg, a low DI on Endoflip suggested a diagnosis of achalasia. Among 49 patients with ineffective esophageal motility (IEM), 12 (24%) had low DI (mean 1.4) and 6 (12%) had SECs. In 37 patients with a normal HRM, 9 (24%) had SECs. Discussion: We found EndoFLIP especially useful in evaluation of patients with EGJOO, IEM and absent contractility in whom it supported dysmotility on the achalasia spectrum in 52%, 24% and 18% of patients respectively. Overall, we found Endoflip guided escalation of therapy in 9% of patients. The clinical implications of the FLIP topography in these cases requires further investigation.
Table 1. Endoflip characteristics and Clinical Impact by HRM associated Diagnosis
Disclosures: Ashton Ellison indicated no relevant financial relationships. Anh Nguyen indicated no relevant financial relationships. Jesse Zhang indicated no relevant financial relationships. Roseann Mendoza indicated no relevant financial relationships. Eitan Podgaetz indicated no relevant financial relationships. Rhonda Souza indicated no relevant financial relationships. Stuart Spechler: Interpace Diagnostics – Consultant. Ironwood Pharmaceuticals – Consultant. Phathom Pharmaceuticals – Consultant. UpToDate – Other Financial or Material Support, Topic author. Vani Konda indicated no relevant financial relationships.